Dialysis patients undergoing PCI often receive contraindicated antithrombotic
MedWire News: A US study reveals that dialysis patients undergoing percutaneous coronary intervention (PCI) often receive antithrombotic medications that are renally cleared and therefore contraindicated or not recommended in this group.
Researchers found that a fifth of dialysis patients undergoing PCI between 2004 and 2008 received a contraindicated antithrombotic, either enoxaparin or eptifibatide. These patients had higher rates of in-hospital major bleeding than those receiving alternative, non-renally cleared antithrombotic drugs.
“This study therefore demonstrates that these medications are used in clinical practice despite FDA [Food and Drug Administration]-directed labeling, and their use is associated with adverse patient outcomes,” write Thomas Tsai (Denver Veterans Affairs Medical Center, Colorado, USA) and team.
The team investigated antithrombotic use among 22,778 dialysis patients who underwent PCI at 829 hospitals across the USA.
As reported in the Journal of the American Medical Association, 5084 (22.3%) patients received a contraindicated antithrombotic, of whom 2375 (46.7%) received enoxaparin, 3261 (64.1%) received eptifibatide, and 552 (10.9%) received both.
These patients had higher unadjusted rates of in-hospital major bleeding (5.6% vs 2.9%, odds ratio [OR]=1.93) and death (6.5% vs 3.9%, OR=1.68) than patients who did not receive a contraindicated antithrombotic.
In multivariable analysis, contraindicated antithrombotic use was independently associated with increased in-hospital major bleeding (OR=1.66) and death (OR=1.24) risks. But in further analysis using propensity matching, it remained significantly associated with increased risk for in-hospital major bleeding only (OR=1.63).
Tsai and team suggest that a lack of direct evidence from clinical trials and studies in routine practice may have contributed to continued use of the contraindicated antithrombotics despite FDA warnings in the medication package inserts and internet-based pharmacy resources advising against their use in dialysis patients.
Noting that their findings appear to validate the FDA-directed labeling, they conclude: “Educational efforts targeting clinicians who prescribe these medications and quality improvement interventions, such as amending clinical pathway order sets to include consideration of renal function, are urgently needed.”
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By Caroline Price